Visante 
As Easter Eggs are hunted this weekend, CMS has picked back up their auditing services which were previously slowed due to Covid. The Targeted Probe and Educate (TPE) program is a way to help you as an organization identify errors and provide one on one help to correct them. The TP&E specifically targets providers or suppliers who have high error claim rates or unusual billing practices and items and services that have high national error rates and are a financial risk to Medicare. Medicare Administrative Contractors (MAC) focus only on providers/suppliers that have been identified as potential risk to Medicare trust funds.
If chosen for a TPE audit, you will receive a letter from your MAC. Approximately 20-40 claims will be selected for review and supporting medical records. If claims are determined to be compliant, the organization will not be reviewed for the selected topic for at least 1 year. If there are claims that are denied, you will be invited to a one-on-one education session. You will be given at least a 45 day period to make changes. Then a new set of 20-40 claims will be reviewed for up to 3 rounds allowing time for the organization to improve billing practices. Claims may be appealed throughout this process and any overturned will be taken into consideration in the error rate. Failure to improve after 3 rounds of reviews, the organization will be referred to CMS for next steps which may include:
100% prepay review
Extrapolation of error rates from a sample of claims with potential of going back 6 years
Referral to Recovery Auditor
Initiation of exclusion of proceedings to terminate your Medicare participation
Referral to Office of Inspector General for further investigation
TPE may also include a targeted review of specific drugs. Some MAC may publish a checklist of common errors that are reviewed; while other MAC provide detailed reasons for denials. For example, denosumab has been a past TPE. Common denials seen with denosumab include lack of documentation to meet medical necessity (e.g. bone scans, indication) and lack of valid physician order with appropriate signature.
Shout-Outs! Appeals/Audit teams to be prepared for the audits and work with the appropriate teams to quickly implement improvement processes prior to the next sample of audits.
Pharmacy teams should attend educational sessions with the MACs to enhance overall response to the audits and strategy to prevent further billing errors.
Continue to self-monitor past reasons for TPE or other prepayment audits to ensure billing systems are set up to minimize risk.
